1. health and fitness
2. disease
3. cancer

Southern California CSU DNP Consortium
California State University, Fullerton
California State University, Long Beach
California State University, Los Angeles
MAMMOGRAPHY DATABASE: ADHERENCE TRACKING FOR WOMAN
VETERANS
A DOCTORAL PROJECT
Submitted in Partial Fulfillment of the Requirements
For the degree of
DOCTOR OF NURSING PRACTICE
By
Yvonne Ginez-Gonzales
Doctoral Project Committee Approval:
Penny Weismuller, DrPH, RN, Project Chair
Dana N. Rutledge, PhD, RN, Committee Member
May 2015
Copyright Yvonne Ginez-Gonzales 2015 ©
ii
ABSTRACT
The Veterans Healthcare Administration (VHA) recognizes women Veterans
(WVs) as the fastest growing demographic group within the Veteran population. To
reduce mortality and deaths from breast cancer, VHA guidelines recommend routine
mammography screenings for women ages 50 to 74. As of Fall 2014, this Southern
California large federal healthcare system (HCS) organization did not have a systematic
way to monitor outpatient WV recommended screening due dates or follow-ups within
the complex electronic healthcare records (EHR). Given this, a population-based
Microsoft Access database was developed as a tool to proactively manage preventive
mammography screenings by serving as a reliable tracking and reminder system. When
used as a tracking tool by system-wide clinics, it will help improve screening adherence,
and should decrease or eliminate the potential that WVs would miss follow-up
appointments for abnormal findings. Following implementation, evaluation of database
effectiveness will include comparison of 3-month baseline preventive performance
measures and abnormal follow-up exams (manual tracking) to a 3-month period after
implementation of the database system. User satisfaction will be assessed using the
Questionnaire for User Interaction Satisfaction (QUIS). Once in use, consideration may
be given to expanding the database to track other key prevention measures (e.g., pap
smears) with appropriate follow-up metrics.
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TABLE OF CONTENTS
ABSTRACT...................................................................................................................
iii
LIST OF TABLES .........................................................................................................
vi
LIST OF FIGURES ....................................................................................................... vii
ACKNOWLEDGMENTS ............................................................................................. viii
BACKGROUND ...........................................................................................................
1
Problem Statement ................................................................................................
1
Local Context for this Problem .............................................................................
3
Recommendation for Practice Change .................................................................
4
Supporting Framework .........................................................................................
6
Project Purpose and Goals .................................................................................... 11
LITERATURE REVIEW ..............................................................................................
12
Evidence Synthesis ...............................................................................................
Women Veteran Characteristics ....................................................................
Characteristics of Women VA Users .............................................................
Access to and Perceptions of Care .................................................................
Evidence-based Recommendations ...............................................................
Use of a Population-based Database to Improve Adherence .........................
13
14
15
15
16
19
METHODS ....................................................................................................................
21
Setting ...................................................................................................................
Description of Project ...........................................................................................
Software Description .....................................................................................
Features of the Database ................................................................................
Database Support ...........................................................................................
Implementation Plan .............................................................................................
Evaluation .............................................................................................................
Implications for Practice .......................................................................................
21
22
22
23
25
26
27
28
CONCLUSION ..............................................................................................................
29
iv
REFERENCES ..............................................................................................................
31
APPENDIX A: FOCUS-PDSA FRAMEWORK PERMISSION EMAIL..................
35
APPENDIX B: SCREENING PROCESS FLOW MAP .............................................
37
APPENDIX C: MICROSOFT ACCESS MAMMOGRAPHY DATABASE
SCREEN SHOTS...............................................................................
38
APPENDIX D: REQUEST FOR QUIS USE PERMISSION .....................................
41
APPENDIX E: QUIS LICENSE AGREEMENT AND QUESTIONNAIRE ............
45
APPENDIX F: TABLE OF EVIDENCE....................................................................
54
v
LIST OF TABLES
Table
1.
Page
FY2013 Breast Screening Performance Measures ..............................................
vi
2
LIST OF FIGURES
Figure
Page
1.
Focus-PDSA Model, adapted for DNP project ....................................................
10
2.
Mammography Access database fields and purpose ...........................................
24
3.
Implementation timeline ......................................................................................
27
vii
ACKNOWLEDGMENTS
I wish to acknowledge and express my loving gratitude to my husband (Blas) and
kids (Nicolas and Chloe) for your endless encouragement and support throughout my
educational endeavors. Your unconditional love, patience and sacrifices were great - I
love you all dearly for being there every step of way.
I would like to express my deepest appreciation to my project chair Penny
Weismuller, Ph.D., R.N. for having faith in me, for her guidance and persistent help with
this DNP project. She played a vital role in my decision-making to continue this journey,
even when there was a moment when I was ready to give up when my project did not
take the expected path. I will be forever grateful for her free therapy sessions to get me
past, what I thought was the demise of my project, to a successful project defense. A
special thanks to Dana N. Rutledge, Ph.D., R.N. for her expertise in helping me see the
possibilities of my DNP project, including its future potential. I was so fortunate to have
her as my committee member and learn from her the phenomenal way she could help me
utilize words to bring impact and meaning to both my paper and my poster.
Finally, a sincere thanks to my DNP Cohort 3 classmates for sharing in this
journey with me, my NP co-workers (Marla and Linda) for their editing and clinical
guidance, the Women’s Health Clinic staff for your dedication and commitment to
improving care for our Women Veterans and lastly Raphael (Raffy) for your technology
support and patience with my learning curve to build this database from the ground up.
viii
1
BACKGROUND
Problem Statement
Within the Veteran Healthcare Administration (VHA), women Veterans (WVs)
are the minority gender (U.S. Department of Veterans Affairs, National Center for
Veterans Analysis and Statistics [USDVA, NCVAS], 2013). The VHA recognizes them
as the fastest growing demographic group within the Veteran population. As of
September 2013, WVs numbered 2,271,222 in the United States. California is one of the
top five states in terms of numbers with 184,774 WVs (USDVA, NCVAS, 2013). In
Southern California, a large federal HCS organization serves approximately 3,184 WVs.
To reduce mortality and deaths from breast cancer, VHA guidelines recommend
routine mammography screenings for women ages 50 to 74 (U.S. Department of Veterans
Affairs, VHA National Center for Health Promotion and Disease Prevention [USDVA,
NCP], 2012). Nationally, breast cancer ranks as one of the three most common cancers
and cancer-related deaths among women (U.S. Department of Health and Human
Services, Center for Disease Control and Prevention and National Cancer Institute
[USDHHS, CDCP & NCI], 2013); early detection has been shown to decrease breast
cancer mortality. The American Cancer Society (ACS) estimates for breast cancer in the
United States in 2015 are about 231,840 new cases of invasive breast cancer will be
diagnosed and about 40,290 women will die from breast cancer (American Cancer
Society [ACS], 2015). Recognizing the high prevalence of breast cancer and the
effectiveness of early detection, the NCP, VHA Directive, and VHA Handbook provide
clinical screening guidelines for breast cancer (USDVA, NCP).
2
In fiscal year 2013, the HCS organization fell below the VHA national standards
in meeting their breast cancer screening performance measure for women ages 50 to 69.
The performance measures are reported by the External Peer Review Program (EPRP),
an external program that is under contract to collect data from electronic medical records
at the VHA. Staff members from EPRP provides the organization with a database of
information that, for each indicator (e.g., breast cancer screening), reflects randomly
sampled persons from the total HCS organization population. Reports from this database
are used in plans for meeting performance measures through comparison, evaluation, and
benchmarking of clinical care with external organizations.
The HCS organization’s 4th quarter 2013 year-to-date breast screening prevention
measure was 71%, compared to the VHA national performance measure at 85% (Table
1). This placed the organizations data two standard deviations below the mean
(statistically different). In October 2013 and the new fiscal year 2014, the performance
measure was changed to include women ages 50 to 74. The change was in response to U.
S. Preventive Services Task Force (USPSTF) and the NCP guidance on clinical
preventive services (USDVA, NCP, 2012; U. S. Preventive Services Task Force
[USPSTF], 2013).
Table 1
FY2013 Breast Screening Performance Measures.
Measure Name
CA – Women
age 50-69
screened for
Breast Cancer
Facility
Quarter Quarter Quarter Quarter
1
2
3
4
FY2013
Cum %
Large Federal
Healthcare
System
62%
81%
73%
53%
71%
National
86%
86%
84%
84%
85%
3
While the federal HCS organization offers services for active duty service
members, dependents of services members, and Veterans, this project will focus only on
women discharged from active duty or released under conditions other than dishonorable
discharge (Moulta-Ali, 2014). According to the NCP, it is important to focus on this
group of WVs to ensure that organization is meeting one of the VHA’s Mission Critical
Measures. The critical measure requirement is achieving breast cancer screenings for
women ages 50 through 74 years to complete mammograms every 1-2 years (USDVA,
NCP, 2012).
In order to meet the national performance measures standards, it is important to
assure that women are compliant with mammograms at the recommended time intervals.
Local Context for this Project
Collaboration began with the Women’s Health Clinic (WHC) in response to the
need to assess the mammography program and improve the performance measures. The
initial aim of this doctoral project was to contribute to the performance improvement of
the mammography program by providing an analysis of WV demographics and
contributing factors that posed potential barriers to prevention screening adherence,
which would have informed recommendations for practice change. Unfortunately, the
project took a turn midway through the doctoral program, when I was faced with the
obstacle of attaining institutional review board approval from the federal HCS.
After returning to the list of challenges reviewed with the WHC staff, the new
focus of the doctoral project became creation of an integrated tracking and follow-up
technology into their current mammography program. The WHC uses the Computerized
Patient Record System (CPRS) mammography clinical reminder system and a weekly list
4
provided of WVs scheduled for an upcoming appointment, not related to mammography,
as tools for prompting communication with WVs. The advantage of this electronic health
record (EHR) is that when WVs have face-to-face visits or any other communications
where the CPRS is accessed, the clinical reminder will display if a mammogram is due,
thus providing an opportunity to communicate the need for a mammography. The
disadvantage is that if the WHC does not have contact with the WV, there is no way to
know whether there is a need for screening or follow-up. As it exists, this system thus
disregards WVs who infrequently visit the WHC, and can delay potential detection and
treatment of breast cancer. To provide reassurance to WHC staff as well as improving
communication and quality of care for WVs, a method for tracking and follow-up would
be of value to decrease missed opportunities for screening, education, and follow-up.
Recommendation for Practice Change
Taking a more proactive role in the health of WVs can provide opportunities to
reach out to the at-risk (overdue) and follow up with balanced education of the risks and
benefits of having mammograms. Having such an outreach provides an opportunity for
WHC staff to have conversations with WVs during calls to inform them of their overdue
mammography.
In an integrative review, Edgar and colleagues (2013) made the following
evidence-based recommendations:
•
Increase women’s knowledge of breast cancer risk factors,
•
Provide flexible appointment days and times to accommodate work and
family,
5
•
Reassurance by health professionals about the mammography experience to
women who disclose feelings of anxiety with preventive screening and breast
cancer by educating about the benefits of early detection and dismissing stoic
views of the disease,
•
Assess the socioeconomic and cultural differences,
•
Support balanced view of benefits and risks (e.g. false positive, false negative,
overtreatment and over diagnosis), and
•
Reach out and engage women in informed decision making with
comprehensive information, assessment and follow-up.
In an interview, the WHC nurse care manager described the current process and
available alerts as appropriate for point-of-care contact. However, she felt that there was
room for improvement to proactively manage this population with a user-friendly system
to track upcoming due dates and necessary follow-ups. Analysis of the current system
identified individual staff calendars being used for tracking and monitoring follow-ups,
challenges with timely communication between deliveries of care, including judicious
follow-ups due to ineffective practices. This helped determine the need for this DNP
project. The WHC could benefit from a monitoring and tracking system (Atlas et al.,
2010; Corkery, 2007). Such systems are often referenced as registries or populationbased databases.
There are multiple benefits in databases of this type. These include the following:
•
Empowering staff to be able to work at the maximum level of licensure with
minimal involvement of providers,
6
•
Using the WHC staff (RN Care Manager, Licensed Vocational Nurse (LVN),
or clerk) to identify patients due for screening through a report from the
database and subsequently, sending a “It’s Time for Your Mammography”
letter and a second follow-up letter if no response or completion of
mammogram,
•
Using the WHC staff to identify WVs who need follow-up and sending an
important reminder letter to call to make an appointment.
Women’s preventive health care is provided in a number of clinics at the federal
HCS including its community-based outpatient clinics (CBOCs) and by various providers
(e.g., medical doctors, nurse practitioners). The implementation of the population-based
database tool will capture and provide meaningful information about WVs, which can be
analyzed to identify specific contributing factors that affect quality outcomes as well as
areas for improvement. Furthermore, it provides a systematic shared approach for
communication and evaluation of the mammography program, which should benefit
multiple clinics.
Supporting Framework
Healthcare organizations use performance improvement models to improve their
performance targeted at improving specific healthcare problems. The literature offers a
variety of frameworks, each with individual benefits and sharing a theoretical base to
improve performance. Performance improvement projects can work best when all team
members agree to a single model to drive their improvements and clarify the outcomes
(Dianis & Cummings, 1998). The conceptual framework chosen for this performance
improvement project will be the FOCUS – PDCA model (Figure 1).
7
The PDCA model adopted by the federal HCS provides the framework for the
pursuit of excellence in the provision of healthcare through a planned, collaborative,
interdisciplinary, organization-wide approach to performance and quality improvement.
The Plan, Do, Check and Act Model was originally developed by Shewhart in the 1920s
and often referred to as the Shewhart cycle. In the early 1950s, Deming modified the
PDCA model and improved its popularity in performance improvement projects. The
FOCUS part of the PDCA model was developed by the Hospital Corporation of America
(Appendix A) to focus on processes as opposed to individuals (Moen & Norman, 2006).
The intent of the FOCUS-PDCA methodology is to develop processes that
directly improve outcomes and advance organizational performance (Taylor et al., 2013).
The “F” in FOCUS is the vital first step to improvement and that would include finding a
process to improve. For the fiscal year 2013, breast cancer clinical screening
performance measures for woman 50 to 69 years of age were inconsistent and fell below
the national benchmark. This concern was acknowledged as a top priority by leaders and
became the focus for this performance improvement project.
The next step is organizing a team that understands the process that is “O” in
FOCUS. The ownership of the performance measures lies with the Women’s Health
Coordinator. To facilitate this, I put together a small team that comprises a Women’s
Designated Provider (WDP), two Registered Nurses (RN) Care Managers, the primary
care clinic supervisor, primary care management analyst and the Women’s Health
Coordinator. All team members have some degree of direct control over care processes
and are the experts in this area of performance improvement.
8
Clarifying the current knowledge of the process is the “C” in FOCUS. It is
important to identify the course of the problem early on to ensure the team is engaged and
understands the focus of the improvement process. Often teams jump precipitously into
making suggestions for process improvements without a clear understanding about
current operations. This can lead to unreliable solutions and make it difficult to reach
complete process analysis. Clarifying the current process requires documenting and
mapping of the current process. It also requires identifying stakeholders who may be
affected by current practices and understanding organizational commitment.
Following the performance improvement model, the “U” in FOCUS is about
understanding causes of process variations. In this step, team members question and
attempt to identify why the current process is not working. Current benchmark data is
acquired to understand the influence of current processes and provide an opportunity to
define variations in the process and indicators of success. The benchmark data will later
be used to compare measures after recommendations are put into practice.
The final step of FOCUS is “S” when the team will select the performance
improvements that will be completed in the process. The team will ensure sufficient data
and evidence-based literature exists to support any potential solutions that are
recommended. There are several opportunities within the process to improve
performance; it is important to consider the improvement opportunity that will most
likely succeed and produce the maximum outcome. The process improvement selected
will provide a reminder tool for RN Care Managers and Providers to contact WVs about
completing a screening mammography at regular intervals, result follow-ups and provide
applicable evidence-based recommendations to improve adherence rates.
9
After the team has clarified current knowledge of the process and process
variations, collected and analyzed benchmark data, and completed all FOCUS steps, they
will move into the PDCA cycle. The initial step of the PDCA cycle is planning the
improvement and how the improvement will be accomplished. Identification of a
measurable outcome is required to determine the degree at which the goal will be
accomplished. Proceeding is the “Do” phase where the pilot test will be implemented
based on identified needs. Observation and data collection occurs during this phase to
ensure the improvement is implemented according to the plan and to determine whether a
revision in the plan is needed. Following the “Do” phase is the “Check” phase. During
the “Check” phase, the team will compare current data to predicted outcomes, and
previous benchmark measures collected prior to implementation of the new process.
Continuing the cycle is the “Act” phase where the results of the planned changed are
accepted and a full scale implementation will occur. If the team did not achieve expected
or anticipated outcome results, the “Act” phase is skipped. The team will return to the
“Plan” phase to develop some new ideas and move through the cycle again. The process
change will need to be documented through policies, procedures, or guidelines. Finally,
changes should be communicated throughout the organization and the monitors should
continue to assess the effectiveness and sustainability of the change over time.
10
Figure 1. Focus-PDSA model, adapted for DNP project.
11
Project Purpose and Goals
The purpose of this quality improvement doctoral project was to address the lack
of a systematic user-friendly documenting tool for tracking mammography screenings
and follow-ups. Integrating evidence-based interventions into the building of the
mammography database, then coupling this information with face-to-face visits with
WHC staff or a telephone reminder call can be used to promote screening and follow-ups.
Prior to this project, there was no significant HCS effort to take on an electronic method;
the practice relies solely on a daily list provided by the management analyst of upcoming
WV appointments.
The goals of the project were to include:
1. Identifying both effective and ineffective strategies and processes used by the
WHC that promote mammography screenings and track follow-ups.
2. Developing a user friendly population-based Access database tool to promote
awareness of upcoming screening reminders, including missed or overdue
screening dates and follow-ups. This was done in collaboration with the
primary care management analyst, and will be piloted for women 40-74 years
of age.
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LITERATURE REVIEW
A review of the literature regarding mammography use among WVs and
contributing factors that affect adherence was completed using PubMed, Cochrane
Library, and Cumulative Index to Nursing & Allied Health Literature (CINAHL)
databases with publication dates from 1998–2014. The range in years allowed for
inclusion of one of the first comprehensive descriptive studies looking at predictors of
WV mammography use (Hynes, Bastian, Rimer, Sloane, & Feussner, 1998). In addition,
this review included studies that explored changes in trends over last 16 years. English
only published studies were chosen since the focus of project is in a VHA facility. The
search terms in PubMed using a Boolean search mode were "Mammography"[Mesh]
AND (("women"[MeSH Terms] OR "women"[All Fields]) AND ("Veterans"[MeSH
Terms] OR "Veterans"[All Fields])) which resulted in 21 peer-reviewed published
articles. Further searches included a combination of PubMed, CINAHL, and Cochrane
Library search using the search terms “mammo*,” “breast screening,” “strateg*,”
“factors,” “barriers,” “health behavior,” “health promotion,” “access,” and “cost.” One
additional separate search returned a surprising zero results which included the terms
“military sexual trauma” and “mammography,” “military sexual trauma” and “breast
cancer screening,” “military sexual trauma” and “women vet*” and “breast,” and finally
“MST” and “women vet*” and “breast.”
Peer-reviewed evidence types included integrative/systematic reviews,
qualitative/quantitative studies, and framework literature. This provided a comprehensive
literature search that supports utilizing the FOCUS-PDCA model. Furthermore, the
qualitative studies can provide background personal beliefs about factors related to breast
13
cancer screenings that can be utilized to support recommendations and findings from
applicable scholarly references that support evidence-based practice educational
materials, telephone response scripts, and program process improvements.
Evidence Synthesis
Among the studies selected, eight of the 14 were published using WVs as the
focus population. An integrated review of 12 research papers (samples from US, UK,
Australia, Canada, and Arab countries) was included that addressed factors that can
influence women’s decisions to get breast cancer screenings (Edgar, Glackin, Hughes, &
Rogers, 2013). A systematic review paper of 26 studies between 1986 and 2004
evaluated the interventions and their effectiveness to increase breast cancer screenings
(Baron et al., 2010). One qualitative study sampled 51 WVs to explore their views and
decision-making about utilizing VA healthcare (Washington, Kleimann, Michelini,
Kleimann, & Canning, 2007). Finally, quantitative studies included were a pragmatic
randomized blinded trial (Fortuna et al., 2013), a prospective randomized control trial
study (Hegenscheid et al., 2011), and seven cross-sectional, descriptive studies
(Dalessandri, Cooper, & Rucker, 1998; Hynes et al., 1998; Lairson, Chan, &
Newmark, 2005; Mengeling, Sadler, Torner, & Booth, 2011; Vogt et al., 2006;
Washington, Bean-Mayberry, Riopelle, & Yano, 2011; Washington, Yano, Simon, &
Sun, 2006). There was a wide range of sample sizes within these 14 studies—from 51
participants in the qualitative study to a larger national electronic database set of 5,477
(Baron et al., 2010; Dalessandri et al., 1998; Edgar et al., 2013; Fortuna et al., 2013;
Hegenscheid et al., 2011; Hynes et al., 1998; Lairson et al., 2005; Mengeling et al., 2011;
Sabatino et al., 2012; Vogt et al., 2006; Washington et al., 2006, 2007, 2011). Three
14
studies addressed screening interventions and recommendations for more than one area of
interest (breast, cervical and colorectal cancer) in non-Veterans (Baron et al., 2010;
Community Preventive Services Task Force [CPSTF], 2012; Sabatino et al., 2012).
Three studies evaluated whether a proactive approach to outreach (i.e., informational
brochure, letter, phone call, scripted telephone counseling, etc.) would increase the use of
mammography in both WVs and the community (Dalesssandri et al., 1998; Fortuna et al.,
2013; Hegenscheid et al., 2011). The integrative review assessed influencing factors
(socio-demographic) that affect participation in breast cancer screening among WVs
(Edgar et al., 2013). Two studies evaluated interventions, socio-demographics, and use of
VA vs. non-VA facility as potential predictors to mammography use (Hynes et al., 1998;
Washington, 2006). Four studies addressed the comprehensive needs, preferences,
barriers, and characteristics of VA women (Lairson et al., 2005; Mengeling et al., 2011;
Vogt et al., 2006; Washington et al., 2011).
Women Veteran Characteristics
WVs are one of the fastest growing groups of Veterans in VA healthcare (Lairson
et al., 2005; Mengeling et al., 2011; Vogt et al., 2006; Washington et al., 2006, 2007,
2011), and are often less healthy than male Veterans or non-Veteran women cohorts
(Vogt et al., 2006). Underutilization of the VA systems of care has been recognized as a
potential barrier to better health (Vogt et al., 2006; Washington et al., 2007). All studies
document that in some way WVs’ socio-demographics, access, lack of knowledge of
women services, barriers to care, and environment perceptions impact usage of VA
clinics/settings for preventive and medical needs.
15
Characteristics of Women VA Users
Recent studies have found sole VA users to be middle age, primarily Caucasian,
likely to be divorced or single, likely to be unemployed, living in low household incomes,
and likely to be uninsured (Mengling et al., 2011; Washington et al., 2007, 2011). Using
a nationally representative sample, Vogt and colleagues (2006) found women VA users
with a service-connected disabilities endured greater challenges with ease of using
facilities, in addition to availability of services than WV with non-service connected
disabilities. Lairson and colleagues (2005) showed that WVs 50 years and older, who
were smokers and in poor health status were less likely to get breast screenings, while
those with more years of education, insurance, higher income, and an individual belief of
supposed risk were more likely to get screened.
Access to and Perceptions of Care
General access barriers for WVs included lower income, greater distance from
mammography imaging center, lack of knowledge about specific health services
(Mengling et al., 2011; Washington et al., 2006, 2011), longer waiting times to get care,
and lack of continuity of care (Vogt et al., 2006).
Perceptions of VHA care sometimes depended on utilization of services, what
someone heard about the care, and lack of information about the ability to receive
services (different from lack of knowledge of women specific services). In general, WVs
lack information about eligibility and availability of services, want sensitive quality care
related to women’s health issues, and feel they are subjected to a male-dominated
atmosphere (Mengeling et al., 2011; Vogt et al., 2006; Washington et al., 2006, 2007,
2011). Furthermore, accessibility to women providers, child care, location, distance and
16
ease of making appointments, and wait time were also important aspects about their
perception of quality of care and decision-making about VA use. Lastly, lack of afterhours access to nonemergency care was also a reason for why WVs use outside
healthcare (Washington et al., 2006).
Evidence-based Recommendations
To effectively influence breast screening adherence rates, key determinants can be
identified to match organizational need. These led to the following recommendations for
mammography programs: (a) know the current practice processes and available
resources, (b) know the makeup of the target population (socio-demographics), (c)
research local needs, and (d) consider local and nonlocal evidence regarding the
usefulness of different interventions (Baron, 2010; CPSTF, 2012; Sabatino et al., 2012).
The Task Force on Community Preventive Services (TFCPS), an independent, nonfederal
task force, published its most recent systematic review, The Guide to Community
Preventive Services (Community Guide), identifying evidence-based population health
interventions to decrease mortality rates, increase life expectancy, and improve quality of
life. This source provides recommendations to assist providers in federal, state, and local
health departments make informed practice decisions.
The TFCPS systematic review findings include client-oriented and provideroriented strategies. The following client-oriented screening intervention strategies
increase breast screening rates: (a) client reminders, (b) small media (e.g., videos, print
materials such as brochures, letters, and newsletters), (c) lessening of structural barriers
and simplifying administrative procedures (e.g., reducing time, decreasing distance,
modifying hours of operations, offering mobile mammography, scheduling assistance,
17
dependent care, transportation, patient navigators, etc.), (d) personalized education, (e)
group education, and (f) reduction of out-of-pocket costs (Baron et al., 2010; CPSTF,
2012; Sabatino et al., 2012). In addition, they also reported a strong evidence base for
provider reminders, recall systems, provider assessments and feedback as intervention
strategies focused on providers. Ratings for the aforementioned strategies were
categorized as strong or had satisfactory evidence that the intervention is effective.
Intervention strategies that did not have sufficient evidence and/or where the evidence
was weak included: (a) client incentives, (b) mass media, (c) provider incentives, and (d)
encouraging informed decision making for breast cancer screenings (CPSTF).
In the first study of WVs regarding breast screening behaviors, Hynes and
colleagues (1998) found that WVs are at high-risk for poor health behaviors. The authors
looked at predictors of mammography while controlling for race, age, military service
time, and VA user status. They found that WVs who were “told” to have a mammogram
by a provider or a nurse were five times more likely (OR 5.41, CI 4.63-6.32) to have ever
had breast cancer screening and nearly twice as likely (OR 1.81, CI 1.57-2.09) to have
had breast cancer screening within the last two years as compared to those who were
“not.” Similarly, Baron and colleagues (2010) found strong evidence that a healthcare
professional reminder call improves mammography screenings in their more recent study.
Hynes and colleagues (1998) also reported that WVs who have served greater than 9.5
years are three times more likely to have a preventive screening than those who have
served less time in the military.
Studies of organizational or community interventions to increase mammography
screening rates have documented several successful strategies. Two systematic reviews
18
reported strong/robust support for client prompts (Baron et al., 2012; Sabatino et al.,
2012) while Sabatino et al. found strong/robust evidence for individual education,
reducing personal costs for screening, and decreasing structural barriers. In a pragmatic
randomized trial of 1000+ women in an urban federal-designated underserved area,
Fortuna et al. (2013) found that both personalized outreach and directed in-reach
(provider prompt) doubled the odds of screening rates over a reminder letter alone. In a
national German breast screening initiative including almost 5500 women (Hegenscheid
et al., 2011), the attendance rates among the intervention group (29.7%) and the control
group (26.1%) showed more of an increase when the women were sent a second reminder
in addition to receiving telephone counseling, showing the benefit of including telephone
counseling along with a written reminder. In a randomized controlled trial of 700+
women Veterans (Dalesssandri et al., 1998), having a nurse follow up call to schedule the
mammogram and answer questions resulted in 5-fold increase in 6-month mammography
rates compared to women who only received a mailed informational letter/brochure.
Despite the method, breast screening rates remained low in these studies with no
screening rates higher than 40% of targeted women.
Hegenscheid and colleagues (2011) followed up their interventions with a
satisfaction survey and the results showed that 33% of German women stated that the
personal counseling influenced their decision to complete a breast screening, 56%
reported that they actually received their breast screening, and 77% approved of the
telephone counseling that could be used to motivate non-responders. Baron et al. (2010)
and Lairson et al. (2005) also reported that a discussion between the healthcare
19
professional and the patient regarding the importance of breast cancer screening can be
an important factor of compliance with screening recommendations.
Use of a Population-based Database to Improve Adherence
Unless appropriate changes are made in management of breast screenings and
follow-ups, there will continue to be variations in performance measures and the potential
for missed follow-ups that can lead to delayed care and treatment. Missed follow-ups of
abnormal mammograms is a quality of care issue (Taplin et al., 2004). An additional
literature search and review was conducted in order to explore the benefits of developing
and utilizing a population-based database for the WHC at the large federal HCS.
The evidence shows that clinical reminders used to support providers at point of
care have aided in improving performance measure compliance (Lester et al., 2009), yet
it has also been reported that with the competing clinical demands and the increased
number of performance measures that they can also be underutilized. Additionally the
authors reported that the point of care reminders were also associated with minimal
improvement in meeting the measures.
According to the Medical Dictionary for the Health Professions and Nursing
(2012) “registries” are databases of patients who share a specific characteristic and can be
classified according to how their populations are defined (cancer, trauma, implants, etc.).
Databases are a computerized method of collecting data that can be used for auditing,
monitoring, and tracking. According to the Agency for Healthcare Research and Quality
(AHRQ), the WHC database would be considered a health services database because of
its purpose of addressing either clinical encounters or procedures like mammography
(Gliklich & Dreyer, 2010). Such databases can identify sub-population patients for
20
proactive care, including timely preventive care (e.g., at appropriate intervals). In
addition, they can allow tracking of abnormal follow-ups and provide queries and reports
to facilitate communication, thus, improving patient safety and quality of care (American
College of Obstetricians and Gynecologists, 2012; Corkery, 2007; Lester et al., 2009;
Osuch, et al., 1995; Taplin, et al., 2004).
21
METHODS
Setting
The practice setting was a women’s health clinic which included two RN care
managers, three LVNs, one clerk, two Physicians, and one NP that is located within a
large teaching VA hospital, located in Southern California. This hospital system is part
of network of facilities which includes four other VA facilities. There are 304 hospital
beds, 110 nursing beds for a total of 414 operating beds as of FY2013. In addition to the
main campus, there are five CBOCs where WV receive their primary and preventive
care. However, the only mammography center is located at the main hospital in a city that
is not central to all the CBOCs (Cabrillo – 7 miles, Whittier/Santa Fe Springs – 16 miles,
Santa Ana – 20 miles, Anaheim – 22 miles, and Laguna Hills – 33 miles).
Strategies used to reach project goals included:
1. Identified and included stakeholders from the WHC (providers, nurse
supervisor, women’s health program coordinator, nursing staff, and ancillary
staff), including radiology. This effort fostered investment in the project and
overcame potential resistance to change.
2. Defined the population (national guidelines, target population eligible)
3. Convened a meeting in September 2014 with stakeholders to discuss current
referral, screening, and follow-up processes and created a screening process
flow map (Appendix B) that identified potential for communication gaps
during care delivery and or at transitions in care, which were considered in the
development of the database to address those gaps.
22
4. Established a collaborative relationship with the primary care management
analyst who provided technical support through meetings as needed. In
addition to technical support the management analyst also agreed to take
ownership and management of the product when implemented.
5. Decided on a timeline to measure progress while working with the clinic
leadership and project team.
6. Reviewed monthly progress with project team to monitor status of database
development beginning October 2014 to March 2015.
7. Worked closely with the primary care manager (designated nurse covering the
mammography program within WHC) to provide feedback on the content,
visuals and usability of the database.
Description of Project
Software Description
Microsoft Access, also known as Microsoft Office Access, is a database
management system from Microsoft that combines the relational (organizes data into one
or more tables (or "relations") of rows and columns, with a unique key for each row)
Microsoft Jet Database Engine (an underlying component of a database, a collection of
information stored on a computer in a systematic way) with a graphical user interface (a
type of interface that allows users to interact with electronic devices through graphical
icons and visual indicators such as secondary notation, as opposed to text-based
interfaces, typed command labels or text navigation) and software-development tools. It
can import or link directly to data stored in other applications and databases. Users can
create tables, queries, forms and reports, and connect them together with macros (Fuller
23
& Cook, 2013; Microsoft Access, n.d.). Additional Access qualities include the ability to
be utilized by multiple users concurrently versus the single user Excel spreadsheet and
ease of use. This project will use the Microsoft Access 2013 version.
Features of the Database
To develop an effective evidence-based database tool, a literature search and
synthesis was conducted that identified relevant attributes and possible contributing
factors that can impact the care management and success of a mammography program. In
collaboration with the WHC care managers and the primary care management analyst,
the author selected key data fields and defined the purpose of each (Figure 2). The goal
of the mammography database was to pre-populate as much as possible with information
from the EHR. Some data elements will need to be manually entered by RN care
managers, LVNs, clinic clerks, or providers.
The development of the database involved considerations about workload and
decisions to be sure it was integrated into the current daily work of staff (Corkery, 2007),
saving time and allowing access to daily updated data. Hortman and Thompson (2005)
defined usability of a system by its functionality and ease of use. To be of maximal
value, a system will be easy to use, and meet the needs of the end user. It can provide a
comprehensive picture of practice patterns, along with detailed reports and graphs.
Basically, the goals of a newly designed system should be to reduce visual, intellectual,
memory, and motor work and ultimately, to remove any feelings of more work imposed
by the new technology (Hortman & Thompson).
24
Data Field
•
Navigation Screen (Default)
(See Appendix C)
•
•
(Screen Shot 1)
Demographics
•
•
•
•
•
(Screen Shot 2)
Mammography Reminder
(Tab One)
(Screen Shot 3)
Notification Attempts (Tab
Two)
(Screen Shot 4)
Abnormal Mammograms
(Tab Three)
(Screen Shot 5)
Notes (Tab Four)
Search Tool
Print Record Button
Close Data Entry Form
Button
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Description
Provides the user with a snap shot of the WVs
demographics and current mammography reminder
Tabs provide the user a way to bring a section to
the front without having to the leave the main
screen
Within the navigation bar are buttons that access
updated reports as needed
Confirms correct patient and contact information
Confirms assignment of Primary Care Provider
Provides an opportunity to ask the WV if they
would like to receive reminders and/or health and
wellness information via email
Provides due date
Determines if WV received a mammogram outside
of the VA and provides an opportunity to confirm
date and location
Track dates Mammography ordered and completed
Determines deferral reason
Determines readiness to get mammography
screening
Tracks dates of phone call attempts
Tracks dates of reminder letters sent
Links to telephone scripts
Links to ready to print reminder letters
Provides BI-RADS (Breast Imaging-Reporting
Data System) results
Confirm need for additional views
Track dates biopsy ordered and completed
Provides biopsy results
Confirm need for breast clinic referral
Links to VHA and local policy, references,
resources
Internal communication tool for approved endusers
Provides a quick way to locate the WVs record by
typing in the last name
Provides only a copy of the current demographic
record and current tab
Closes only the current record
Close entire database and prompts user to save any
changes
Figure 2. Mammography Access database fields and purpose.
Finish Button
25
The mammography database is intended to allow WHC user to have immediate
access to key information related to WV mammography status in one screen versus
taking time to search through multiple sections in CPRS. There are a number of valuable
queries and audits that can be accessed, but not limited to the following examples:
mammography due dates to initiate reminder letters or calls, a list of reasons for denials
and readiness to get a mammography in planning for appropriate interventions, zip codes
of WV residences to assess potential distance barrier to the clinic for a mammography,
and finally dates of birth by month to send an “It’s Your Birthday” with wellness wishes
from the WHC and reminders about prevention screenings for their age decade including
health and wellness tips, which in turn supports the patient-centered philosophy of the
federal HCS. Tracking and trending reports, but not limited to the following are: viewing
the provider’s panels and completions rates, review of ordering and mammography
completion rates, including compliance with notification requirements of abnormal
results and follow-ups. The results from the tracking and trending provide a cyclic quality
improvement process that includes entering data, benchmarking, analyzing and
developing and implementing any necessary improvement plan.
Database Support
The Microsoft Access tracking database will be located in the WHC secured
network shared drive, which provides for the security of data information behind the
agency firewall, as the access can be limited to only those given permission. The
management analyst will play a significant role in the importing of actual patient data
from the regional data warehouse (RDW) into the Access database including writing the
programming that will link the database to the RDW for nightly updates. This can keep
26
the database current, ensuring the consistency of data sought (e.g., adding new patients,
hiding expired patients, updating reminders, and any other data element that can be
linked to the RDW).
Implementation Plan
The database pilot will occur in the WHC and one of the five CBOCs (Figure 3).
A mock mammography database copy will be used for training. Training will occur in
phases by utilization need (RN care managers, LVNs, clerks, and then, providers).
Permissions to shared drive will need to be confirmed. The mammography database
introduction training will be provided by the author in multiple scheduled presentations
that will include the following:
•
Explaining the need that prompted development of an evidence-based
supported database,
•
Addressing the benefits of design and content collaboration driven by the
nurses,
•
Reassuring and demonstrating how it was integrated into current workload,
•
Defining the potential quality improvement goal outcomes, and
•
Reflecting on how it supports patient-centered health and wellness to improve
WV satisfaction.
The hands on mammography database training will be completed in the computer
lab, in addition to one-on-one support that will include: a tour of the database, data entry,
running reports, accessing links, printing embedded letters and trouble shooting. A
handbook with screenshots of the database will also be included to provide step by step
instructions and who to contact if something is wrong.
27
Figure 3. Implementation timeline.
Evaluation
Upon database completion, the next step is “Do” in the FOCUS-PDCA model.
This will be to pilot the product in the WHC. Hortman and colleagues (2005) defined
five quality components to consider when evaluating how easy a database design is
functionally. They include (1) learnability, (2) efficiency, (3) memorability, (4) errors
and (5) satisfaction.
It will be important during the pilot phase to listen for what the end users say and
observe their success or difficulty with product. This will be done during the “Check”
step, along with comparing current data to predicted outcomes and previous benchmarks
for the national EPRP measures (collected prior to implementation). To assess user
satisfaction, a survey tool will be used. The Questionnaire for User Interaction
Satisfaction (QUIS) Version 7.0 is a 12-part questionnaire with multiple questions in
28
each part that was developed by a multi-disciplinary team to assess users’ subjective
satisfaction with specific aspects of a software program (Appendix D). The QUIS
licensing agreement has been obtained and includes the paper document (Appendix E)
which includes a demographic questionnaire and uses six scales to measure overall
system satisfaction and nine specific interface factors (screen factors, terminology and
system information, learning, system capabilities, technical manuals and on-line help, online tutorials, multimedia, teleconferencing, software installation).
A formal evaluation of the database is important to support changes during the
performance improvement cycle. Until the results of the planned changed are accepted
and full implementation occurs then the team will skip the “Act” phase and return to the
“Plan” to make changes in the database and repeat the cycle.
Implications for Practice
Research has suggested that implementing proven evidence-based strategies that
improve women’s breast screening adherence rates could potentially reduce the mortality
and morbidity of breast cancer through early discovery, when treatment is more likely to
be helpful (Baron et al., 2010; CPSTF, 2012; Dalessandri, et al, 1998; Fortuna et al.,
2013; Hegenscheid et al., 2011; Hynes et al., 1998; Sabatino et al., 2012). Furthermore,
standardizing this federal HCS practice can lead to continuity of prevention screening
across this organization and decrease missed opportunities for timely completion of
mammography (Edgar et al., 2013; Lairson et al., 2005; Mengeling et al., 2011; Vogt et
al., 2006; Washington et al., 2006, 2007, 2011). Evidence of improvements in
mammography rates should be observed in the future EPRP reports; after introduction of
29
the mammography Microsoft Access database for regular reminders for screening and
follow-ups.
CONCLUSION
As our nation’s heroes, WVs deserve and have earned the right to the best
healthcare access that our VHA system of care can provide for their contributions and
sacrifices for family and nation. Increases in numbers of WVs accessing VHA care make
it important to deliver timely services attentive to women’s health needs. This may
include prevention screenings, wellness and reproductive health, mental health, geriatric
and perhaps extended care. This large federal HCS did not meet its FY 2013
mammography performance measures. It was time for action and as a WV who receives
care within this HCS, it became evident to me that this was my opportunity to improve an
area of nursing practice that I felt passionate about and which affected outcomes for WVs
as well as myself. It was my commitment to WV quality and satisfaction with care that
drove this doctoral project.
Mammography performance measures should be improved by implementing the
newly developed user-friendly database tracking tool. The FOCUS-PDCA model
provided a useful framework in developing the Microsoft Access database tool that
focuses on the mammography screening process, the needs of WVs, and the wants of the
end users. The RN Care Managers, LVNs, Providers and office staff need an effective
way to communicate, coordinate and follow-up on WV preventive screenings and results.
It is anticipated that the database will directly impact and improve the
organization’s mammography performance measures, while enhancing WV and staff
satisfaction. Improving access to care and adherence to guidelines using this database are
30
only a part of the management of this special group of Veterans. In the future, it is hoped
that information about WVs as related to additional screening measures (pap smear and
colonoscopy) may be added to the database. This would show its utility.
31
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Lairson, D. R., Chan, W., & Newmark, G. R. (2005). Determinants of the demand for
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Lester, W. T., Ashburner, J. M., Grant, R. W., Chueh, H. C., Barry, M. J., & Atlas, S. J.
(2009). Mammography fast track: An intervention to facilitate reminders for
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Mengeling, M. A., Sadler, A. G., Torner, J., & Booth, B. M. (2011). Evolving
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Microsoft Access. (n.d.). In Wikipedia. Retrieved January 4, 2015, from
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Moulta-Ali, U. (2014). Who is a veteran? – Basic eligibility for veterans’ benefits.
Congressional Research Service, 1-10. Retrieved from
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Osuch, J. R., Anthony, M., Bassett, L. W., DeBor, M., D'Orsi, C., Hendrick, R. E., . . . &
Smith, R. (1995). A proposal for a national mammography database: Content,
purpose and value. American Journal of Roentgenology, 164(6), 1329-1334.
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interventions to increase screening for breast, cervical, and colorectal cancers:
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Taplin, S. H., Ichikawa, L., Yood, M. U., Manos, M. M., Geiger, A. M., Weinmann, S.,
… & Barlow, W. E. (2004). Reason for late-stage breast cancer: Absence of
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Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2013).
Systematic review of the application of the plan-do-study-act method to improve
quality in healthcare. British Medical Journal Quality and Safety Online First, 19. doi: 10.1136/bmjqs-2013-001862
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Prevention and National Cancer Institute. (2013). U. S. cancer statistics working
group: United States cancer statistics: 1999–2010 incidence and mortality webbased report. Retrieved from http://apps.nccd.cdc.gov/uscs/toptencancers.aspx
U. S. Department of Veterans Affairs, VHA National Center for Health Promotion and
Disease Prevention. (2012). Screening for breast cancer. Retrieved from
http://vaww.prevention.va.gov/Screening_for_Breast_Cancer.asp
U. S. Department of Veterans Affairs, National Center for Veterans Analysis and
Statistics. (2013, February). Women veterans population fact sheet. Retrieved
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U. S. Department of Veterans Affairs, National Center for Veterans Analysis and
Statistics. (2013, October). Women veteran profile. Retrieved from
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Washington, D., Kleimann, S., Michelini, A., Kleimann, K., & Canning, M. (2007).
Women veterans perceptions and decision-making about Veterans Affairs Health
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Washington, D. L, Yano, E. M., Simon, B., & Sun, S. (2006). To use or not to use: What
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White, B. (1999). Building a patient registry from the ground up. Family Practice
Management, 6(10), 43-46.
35
APPENDIX A
FOCUS-PDSA FRAMWORK PERMISSION EMAIL
RE: Request for permission to use Intellectual Property
From: Alexander, Miles ([email protected])
Sent: Mon 3/03/14 8:27 AM
To: Yvonne Ginez-Gonzales ([email protected])
Good morning – wish I could help but we no longer handle trademark matters for this
client and I do not know who does so. I do not believe that HCA has a client of our firm
for many years.
Sincerely,
Miles
Miles Alexander
Kilpatrick Townsend & Stockton LLP
Suite 2800 | 1100 Peachtree Street NE | Atlanta, GA 30309-4528
office 404 815 6410 | cell 404 394 4649 | fax 404 541 3105
[email protected] | My Profile | vCard
From: Yvonne Ginez-Gonzales [mailto:[email protected]]
Sent: Sunday, March 02, 2014 6:59 PM
To: Alexander, Miles
Subject: Request for permission to use Intellectual Property
Good evening Mr. Alexander,
My name is Yvonne Ginez-Gonzales. I located your name at the website Legal Force Trademarkia as the correspondent for the FOCUS-PDCA model. I am a first year student
at California State University, Fullerton (CSUF) in their Doctorate of Nursing Practice
(DNP) program. I will be participating in and leading a performance improvement
project at VA Long Beach Healthcare System in California, where I am employed. The
purpose for my email is to request permission for use of the FOCUS-PDCA model that is
trademarked by the Hospital Corporation of America. During my literature review for
my project which focuses on improving the breast cancer screening adherence rates for
our women veterans, I came across the FOCUS-PDCA model and believe it meets the
needs of my project. VA Long Beach currently utilizes Deming’s PDCA model and has
adopted it for all of its performance improvement projects. However, I appreciate the
adaptation of the FOCUS methodology that was utilized in an article called The FOCUSPDCA Strategy by a number of editors Merritt and colleagues located at
http://centralstatehospital.org/policy/plan8.10A.pdf. In order to move forward with my
project and to go to defense I need an official notification that I have permission to utilize
this model in my project. If you have any questions, please do not hesitate to contact me
36
at [email protected]. I look forward to your response that I may move
forward in a timely manner with my project deadline.
Respectfully yours,
Yvonne Ginez-Gonzales, MSN, RN, NE-BC
Doctorate of Nursing Practice Student
Confidentiality Notice:
This communication constitutes an electronic communication within the meaning of the Electronic Communications Privacy Act, 18 U.S.C.
Section 2510, and its disclosure is strictly limited to the recipient intended by the sender of this message. This transmission, and any
attachments, may contain confidential attorney-client privileged information and attorney work product. If you are not the intended recipient,
any disclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY
PROHIBITED. Please contact us immediately by return e-mail or at 404 815 6500, and destroy the original transmission and its attachments
without reading or saving in any manner.
***DISCLAIMER*** Per Treasury Department Circular 230: Any U.S. federal tax advice contained in this communication (including any
attachments) is not intended or written to be used, and cannot be used, for the purpose of (i) avoiding penalties under the Internal Revenue
Code or (ii) promoting, marketing or recommending to another party any transaction or matter addressed herein.
37
APPENDIX B
SCREENING PROCESS FLOW MAP
38
APPENDIX C
MICROSOFT ACCESS MAMMOGRAPHY DATABASE SCREEN SHOTS
39
40
41
APPENDIX D
REQUEST FOR QUIS USE PERMISSION
Yvonne Ginez-Gonzales <[email protected]>
Request QUIS use permission for Doctoral Project
4 messages
Yvonne Ginez-Gonzales <[email protected]>
Tue, Feb 10, 2015 at
10:23 AM
To: [email protected]
Greetings Dr. Shneiderman,
My name is Yvonne Ginez-Gonzales and I am a Doctor of Nursing Practice student at
California State University, Fullerton with an expected graduation date of May 2015.
I am requesting to permission to use your long form and short form paper versions of
QUIS. I did go online and sign the licensing agreement and have access, but would
like to have an email acknowledgement for my paper.
I came across your questionnaire doing research for my DNP project in a paper by,
Hortman, P. A., & Thompson, C. B. (2005). Evaluation of user interface satisfaction
of a clinical outcomes database. Computers Informatics Nursing, 23(6), 301-307.
I work at VA Long Beach Healthcare System in Long Beach, CA and have almost
completed my Microsoft Access 2013 database that I would like to pilot and
implement to track our women Veterans Mammography compliance and follow-up.
The end-users are in our Women's Health Clinic and have been included with the
development from the beginning providing content and design suggestions.
I would like to be able to evaluate their satisfaction after piloting and again after full
implementation. I believe your questionnaire tool can be of value. I also wanted to
know if you have a paper that provides the reliability and validity of questions.
Finally, do you require additional permission request if I would like to omit questions
that I do not feel meet the need of the information sought?
Thank you for you time to address my request and questions. I look forward to your
email.
Respectfully yours,
Yvonne Ginez-Gonzales, MSN, RN, NE-BC
[email protected]
Ben Shneiderman <[email protected]>
To: Yvonne Ginez-Gonzales <[email protected]>
Tue, Feb 10, 2015 at 10:31 AM
42
Cc: "Kent L. Norman ([email protected])" <[email protected]>
Thanks for your interest… I am copying to my colleague Kent Norman, who handles
these requests….
I saw your earlier note,… so I am using a different email to reach Prof. Norman …
Best wishes… Ben Shneiderman
From: Yvonne Ginez-Gonzales [mailto:[email protected]]
Sent: Tuesday, February 10, 2015 1:23 PM
To: Ben Shneiderman
Subject: Request QUIS use permission for Doctoral Project
Kent L. Norman <[email protected]>
To: Yvonne Ginez-Gonzales <[email protected]>
Cc: bshneide-contact <[email protected]>
Thu, Feb 12, 2015 at 10:34 AM
Dear Yvonne:
Your email was forwarded to me from Dr. Shneiderman.
Technically you need to license the use of QUIS through
Office of Technology Commercialization
Attention: Dan Eastman (Administrative
Assistant)
The University of Maryland
2130 Mitchell Building
College Park, MD 20742-5213
(301) 405-3947
(301) 314-9502 (fax)
[email protected]
If you go to http://lap.umd.edu/quis/ you will find information and papers on the reliability and validity
of the QUIS under Technical Support and References.
There is no problem adding and omitting some questions as you wish.
Sounds like a great project.
Best wishes in your research and study.
Kent
************************************************************
Dr. Kent L. Norman, Associate Professor
Department of Psychology, University of Maryland
College Park, MD 20742
Tel: (301) 405-5924
Fax: (301) 314-9566
Email: [email protected]
Laboratory for Automation Psychology:
43
http://lap.umd.edu
Human-Computer Interaction Laboratory:
http://www.cs.umd.edu/hcil
Web courses:
http://cognitron.umd.edu/
Cyberpsychology: An Introduction to the Psychology of Human-Computer Interaction
http://www.cambridge.org/us/catalogue/catalogue.asp?isbn=9780521687027
Yvonne Ginez-Gonzales
<[email protected]>
To: [email protected]
Thu, Feb 12, 2015 at 11:43 AM
Dear Mr. Eastman,
I have been forwarded your name from Dr. Norman to request permission for use of
QUIS tool. Please see purpose in previous emails below. I have to submit my paper to
my committee reader next week and hope to hear from you before then. If you have
any questions please contact me at my email [email protected]. I
look forward to your response.
Respectfully your,
Yvonne Ginez-Gonzales, MSN, RN, NE-BC
CSUF DNP Student
[Quoted text hidden]
--
Yvonne Ginez-Gonzales
Yvonne Ginez-Gonzales
<[email protected]>
QUIS Licensing information
1 message
Daniel Benedict Eastman <[email protected]>
Thu, Feb 12, 2015 at 12:37 PM
To: "[email protected]" <[email protected]>
Ms. Ginez-Gonzales,
In response to your questions regarding QUIS 7.0 (Questionnaire for User Interaction
Satisfaction), the pricing for a site license is as follows:
Student Paper Version: $ 50.00 // Web version free with purchase of paper
version
*Note that the Web Version no longer has any technical support from its
creators, so it will be free with the purchase of the paper version.
44
You may pay using a check (payment in U.S. dollars, drawn on a U.S. bank, made
payable to the University of Maryland and mailed to the address below),purchase
order (mailed or faxed) or a credit card. We do not currently accept wire transfers.
If you pay with a credit card, we need the following information (faxed, phoned or emailed):
Card name (Visa, Mastercard or Discover)
Card number
Card expiration date
Exact name on the card
Billing address
A unique User ID and Password will be mailed as soon as the check clears or the
credit card has been approved by the campus business office. Please visit the QUIS
website for additional information at: http://lap.umd.edu/quis
This procedure should take a week or less. If you need your purchase expedited, let
me know and I can send you your username and password on receipt of your payment
information.
If you have any questions please do not hesitate to contact us. Also, you may visit our
web site atwww.otc.umd.edu.
Thank you.
Dan Eastman, Admin Assistant
University of Maryland
Office of Technology Commercialization
2130 Mitchell Building
College Park, MD 20742
301-405-3947
FAX: 301-314-9502
45
APPENDIX E
QUISTM LICENSE AGREEMENT AND QUESTIONNAIRE
1. Definitions: "QUISTM" means the "Questionnaire for User Interaction Satisfaction"
(Copyright © 1984, 1993, 1998. University of Maryland. All rights reserved.). "Licensed
Materials" means the electronic and paper versions of QUISTM and all documentation
included in this package and any modifications or updates of said materials delivered to
Licensee. "Licensor" means the University of Maryland. "Licensee" means the individual
or organization licensing and opening this package.
2. Grant of License: In consideration of the payment of the fees and charges paid and the
obligations undertaken by Licensee, Licensor grants to Licensee a nonexclusive,
nontransferable license to the Licensed Materials.
3. Scope and Limitations of Rights:
QUISTM SITE LICENSE: Licensor grants to Licensee the right to copy, modify,
distribute and use the Licensed Materials throughout a single enterprise located within
one building, or buildings, all of which are addressable by only a single postal address.
4. Support and Operation:
4.1 Licensee is responsible for the application and implementation of new releases,
computer program code corrections, and updates to the documentation issued to Licensee
by Licensor. Licensor is not responsible for use of superseded, outdated or uncorrected
versions of the Licensed Materials nor for obsolescence of the Licensed Materials that
may result from changes in Licensee’s requirements or software or equipment not
supplied by Licensor.
4.2 Licensor shall not be responsible for the correction of any error attributable to
Licensee’s misuse or improper use of Licensed Materials, nor shall Licensor be
responsible for maintaining computer program code which has been modified after
delivery by Licensor.
5. Proprietary Protection:
5.1 Licensee acknowledges that the Licensed Materials are a commercially valuable
proprietary product of Licensor and that Licensor is the owner of all right, title and
interest in and to the Licensed Materials and all modifications and enhancements thereto
(including ownership of all trade secrets, copyrights and patents pertaining thereto and
subsisting therein) subject only to the rights and privileges expressly granted by Licensor.
This agreement grants Licensee only a right of limited use, revocable in accordance with
the terms hereof. Licensee shall keep the Licensed Materials free and clear of all claims,
liens, and encumbrances.
46
5.2 Licensee shall not use, distribute, allow access to, copy, or modify the Licensed
Materials, or any copy, adaptation, transcription or merged portion thereof, except as
expressly authorized by this Agreement.
5.3 Licensee’s obligations hereunder shall survive termination of this Agreement and
shall remain in effect for as long as Licensee continues to use, possess or have access to
the Licensed Materials.
6. Disclaimer of Warranty and Limitation of Liability:
6.1 THE LICENSED MATERIALS ARE MADE AVAILABLE ON AN "AS IS"
BASIS. EXCEPT AS EXPRESSLY SET FORTH IN THIS AGREEMENT, LICENSOR
DISCLAIMS ANY AND ALL PROMISES, REPRESENTATIONS AND
WARRANTIES BOTH EXPRESS AND IMPLIED WITH RESPECT TO THE
LICENSED MATERIALS AND ANY SUPPORT SERVICES PROVIDED
HEREUNDER, INCLUDING THEIR CONDITION, CONFORMITY TO ANY
REPRESENTATION OR DESCRIPTION, THE EXISTENCE OF ANY PATENT
DEFECTS THEREIN, AND THEIR MERCHANTABILITY OR FITNESS FOR A
PARTICULAR USE OR PURPOSE.
6.2 In no event shall Licensor be liable for any business expense, machine down time,
loss of profits, any incidental, special, exemplary or consequential damages, or any
claims or demands brought against Licensee or Licensee’s customers, even if Licensor
has been advised of the possibility of such claims or demands. This limitation upon
damages and claims is intended to apply without regard to whether other provisions of
this Agreement have been breached or have proven ineffective.
7. Term and Termination:
7.1 This agreement shall automatically terminate if Licensee uses, distributes, allows
access to, copies, or modifies the Licensed Materials, or if Licensee transfers possession
of any copy, adaptation, transcription or merged portion of the Licensed Materials to any
other party in any way not expressly authorized by this Agreement.
7.2 Termination of this agreement shall not relieve either party of the obligations arising
hereunder before termination. Upon termination, Licensee must return, or certify the
destruction of (and erasure from any storage device), all copies of the Licensed Materials.
8. General:
8.1 It is agreed that the laws of the State of Maryland will govern without reference to
conflict of law principles. Any and all legal actions must be brought in the courts in the
State of Maryland or in the U.S. District Court for the District of Maryland. Licensee
consents to the jurisdiction of said courts.
47
8.2 No modification of this Agreement shall be binding unless it is written and signed by
an authorized representative of the party against whom enforcement of the modification
is sought.
8.3 Neither this Agreement, the License granted hereby, nor any part thereof may be
assigned or otherwise transferred by Licensee.
8.4 In the event that any of the terms of this Agreement is, or becomes, or is declared to
be invalid or void by any court or tribunal of competent jurisdiction, such term or terms
shall be null and void and shall be deemed severed from this Agreement and all the
remaining terms of this Agreement shall remain in full force and effect.
8.5 No action, regardless of form, arising out of this Agreement, except an action by the
University of Maryland for enforcement of its intellectual property rights or damages
resulting from Licensee’s breach thereof, may be brought by either party more than one
(1) year after the cause of action has arisen.
Should you have any questions concerning this Agreement, or if you wish to contact the
University of Maryland for any reason, please write:
Office of Technology Commercialization
University of Maryland
0133 Cole Student Activities Building
College Park, MD 20742-1001
48
QUESTIONNAIRE FOR USER INTERACTION SATISFACTION (QUIS)
SHORT VERSION 7.0
Identification number:
System code:
Age:
Gender:
_______________________
_______________________
______
____ male
____ female
PART 1: System Experience
1.1 How long have you worked on this system?
__
__
__
__
__
less than 1 hour
1 hour to less than 1 day
1 day to less than 1 week
1 week to less than 1 month
1 month to less than 6 months
__
__
__
__
6 months to less than 1 year
1 year to less than 2 years
2 years to less than 3 years
3 years or more
1.2 On the average, how much time do you spend per week on this system?
__ less than one hour
__ one to less than 4 hours
__ 4 to less than 10 hours
__ over 10 hours
PART 2: Past Experience
2.1 How many operating systems have you worked with?
__ none
__ 1
__ 2
__ 3-4
__ 5-6
__ more than 6
2.2 Of the following devices, software, and systems, check those that you have
personally used and are familiar with:
__
__
__
__
__
__
__
__
__
__
computer terminal
personal computer
lap top computer
color monitor
touch screen
floppy drive
CD-ROM drive
keyboard
mouse
track ball
__
__
__
__
__
__
__
__
__
__
joy stick
pen based computing
graphics tablet
head mounted display
modems
scanners
word processor
graphics software
spreadsheet software
database software
__ computer games
__ voice recognition
__ video editing systems
__ CAD computer aided
design
__ rapid prototyping systems
__ e-mail
__ internet
49
PART 3: Overall User Reactions
Please circle the numbers which most appropriately reflect your impressions about using this computer
system. Not Applicable = NA.
3.1 Overall reactions to the system:
3.2
3.3
3.4
3.5
3.6
terrible
wonderful
1 2 3 4 5 6 7 8 9
NA
frustrating
satisfying
1 2 3 4 5 6 7 8 9
NA
dull
stimulating
1 2 3 4 5 6 7 8 9
NA
difficult
easy
1 2 3 4 5 6 7 8 9
NA
inadequate
adequate
power
power
1 2 3 4 5 6 7 8 9
NA
rigid
flexible
1 2 3 4 5 6 7 8 9
NA
PART 4: Screen
4.1 Characters on the computer screen
4.2 Highlighting on the screen
4.3 Screen layouts were helpful
4.4 Sequence of screens
hard to read
easy to read
1 2 3 4 5 6 7 8 9
NA
unhelpful
helpful
1 2 3 4 5 6 7 8 9
NA
never
always
1 2 3 4 5 6 7 8 9
NA
confusing
clear
1 2 3 4 5 6 7 8 9
NA
Please write your comments about the screens here:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
50
PART 5: Terminology and System Information
5.1 Use of terminology throughout system
5.2 Terminology relates well to the work
you are doing?
5.3 Messages which appear on screen
5.4 Messages which appear on screen
5.5 Computer keeps you informed about
what it is doing
5.6 Error messages
inconsistent
consistent
1 2 3 4 5 6 7 8 9
never
always
1 2 3 4 5 6 7 8 9
inconsistent
consistent
1 2 3 4 5 6 7 8 9
confusing
clear
1 2 3 4 5 6 7 8 9
NA
NA
NA
NA
never
always
1 2 3 4 5 6 7 8 9
NA
unhelpful
helpful
1 2 3 4 5 6 7 8 9
NA
Please write your comments about terminology and system information here:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
PART 6: Learning
6.1 Learning to operate the system
6.2 Exploration of features by trial and error
6.3 Remembering names and use of commands
6.4 Tasks can be performed in a straight-forward
manner
difficult
easy
1 2 3 4 5 6 7 8 9
discouraging
encouraging
1 2 3 4 5 6 7 8 9
difficult
easy
1 2 3 4 5 6 7 8 9
never
always
1 2 3 4 5 6 7 8 9
NA
NA
NA
NA
Please write your comments about learning here:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
51
PART 7: System Capabilities
7.1 System speed
7.2 The system is reliable
7.3 System tends to be
7.4 Correcting your mistakes
7.5 Ease of operation depends on your
level of experience
too slow
fast enough
1 2 3 4 5 6 7 8 9
NA
never
always
1 2 3 4 5 6 7 8 9
NA
noisy
quiet
1 2 3 4 5 6 7 8 9
NA
difficult
easy
1 2 3 4 5 6 7 8 9
NA
never
always
1 2 3 4 5 6 7 8 9
NA
Please write your comments about system capabilities here:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
PART 8: Technical Manuals and On-line help
8.1 Technical manuals are
8.2 Information from the manual is
easily understood
8.3 Amount of help given
confusing
clear
1 2 3 4 5 6 7 8 9
never
always
1 2 3 4 5 6 7 8 9
inadequate
adequate
1 2 3 4 5 6 7 8 9
NA
NA
NA
Please write your comments about technical manuals and on-line help here:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
52
PART 9: On-line Tutorials
9.1 Tutorial was
9.2 Maneuvering through the tutorial was
9.3 Tutorial content was
9.4 Tasks can be completed
9.5 Learning to operate the system using the
tutorial was
useless
helpful
1 2 3 4 5 6 7 8 9
difficult
easy
1 2 3 4 5 6 7 8 9
useless
helpful
1 2 3 4 5 6 7 8 9
NA
NA
NA
with difficulty
easily
1 2 3 4 5 6 7 8 9
NA
difficult
easy
1 2 3 4 5 6 7 8 9
NA
Please write your comments about on-line tutorials here:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
PART 10: Multimedia
10.1 Quality of still pictures/photographs
10.2 Quality of movies
10.3 Sound output
10.4 Colors used are
bad
good
1 2 3 4 5 6 7 8 9
NA
bad
good
1 2 3 4 5 6 7 8 9
NA
inaudible
audible
1 2 3 4 5 6 7 8 9
NA
unnatural
natural
1 2 3 4 5 6 7 8 9
NA
Please write your comments about multimedia here:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
53
PART 11: Teleconferencing
11.1 Setting up for conference
11.2 Arrangement of windows showing
connecting groups
11.3 Determining the focus of attention during
conference was
11.4 Video image flow
11.5 Audio output
11.6 Exchanging data
difficult
easy
1 2 3 4 5 6 7 8 9
NA
confusing
clear
1 2 3 4 5 6 7 8 9
NA
confusing
clear
1 2 3 4 5 6 7 8 9
NA
choppy
smooth
1 2 3 4 5 67 8 9
NA
inaudible
audible
1 2 3 4 5 6 7 8 9
NA
difficult
easy
1 2 3 4 5 6 7 8 9
NA
Please write your comments about teleconferencing here:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
PART 12: Software Installation
12.1 Speed of installation
12.2 Customization
12.3 Informs you of its progress
12.4 Gives a meaningful explanation when failures
occur
slow
fast
1 2 3 4 5 6 7 8 9
NA
difficult
easy
1 2 3 4 5 6 7 8 9
NA
never
always
1 2 3 4 5 6 7 8 9
NA
never
always
1 2 3 4 5 6 7 8 9
NA
Please write your comments about software installation here:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
APPENDIX F
TABLE OF EVIDENCE
Table 1
Factors Related To Mammography Use among Women Veterans and the Impact of Current Practice Structure
Purpose
To assess the use of
screening reminders,
recall, & outreach
for cancer. (BS &
CRS)
(Fortuna et al.,
2013).
Design, Key
Variables
Pragmatic
randomized trialstaff blinded
Off-site blinded
statistician
assigned 1,008 pts.
into one of four
intervention groups
(BS, CRS, or both),
stratified by
screening required.
Sample/Setting
Rochester, New
York, mainly lowincome,
disproportionately
minority pt. pop.,
urban federaldesignated
(academic practice)
underserved area.
Prospective RCT
1.
2.
Greifswald
Mammo - screening
unit (1 of 4 units) in
MecklenburgVonpommern in
4.
Letter only (157)
Letter + Autodial
(158)
Letter + Autodial
+ Prompt -inreach (156)
Letter + Personal
Call (PC) –
Outreach (153)
Telephone
counseling, February
to July 2008
Mammo use within 3
months after the
Key Findings
Letter vs letter &
PC 17.8% vs.
27.5%; AOR 2.2,
95% CI 1.1-3.9) –
PC more effective
Letter vs. letter,
autodial, & prompt
(17.8% vs. 28.2%;
AOR 2.1, CI 1.13.7)
Author Conclusions
Personalized
outreach & directed
in-reach (provider
prompt) most
effective to ↑
screening rates than
a reminder letter
alone
Limitations,
Notes
Setting is not
generalizable;
baseline screening
rates were rather
low. Possible pts.
may have had an
undocumented
BS. Cost was not
assessed.
Barrier-specific
counseling in
addition to a
reminder for nonresponders ↑ BS
No demographic
background
collected, low
reach of
telephone
Letter vs. letter &
autodial – not more
effective
Group #4 more
BS with call than
those not reached
(30.9% vs. 20.2%;
P = 0.05)
Screening
attendance ↑intervention grp.
(Telephone &
letter) vs. control
54
IV: Telephone
Counseling,
Attendance in a
4 Groups (BS only)
3.
50-74 yrs. old
men/women for
CRS (629)
40-74 yrs. old,
women past due for
BS (624)
BS evaluation of
telephone advising
& turnout in national
BS program.
Measures
Reminder, recall, &
outreach (RRO)
model
Purpose
(Hegenscheid et al.,
2011).
Design, Key
Variables
national BS
program
DV: BS
completion
Sample/Setting
Germany
Measures
reminder.
5,477 women aged
50-69 yrs. old – non
responders,
Intervention group
(2455), Control
group (2952)
Reminder letter to
control group,
Reminder letter &
telephone counseling
– intervention group
Satisfaction Survey:
To ask counseled
women about
telephone counseling
experience, & if it
influenced decision
to get BS, & sociodemographic data.
Women Veteran
(WV)
characteristics,
needs, & preferences
in VA system of
care.
(Mengeling, Sadler,
Torner, & Booth,
2011)
Descriptive,
Quantitative,
Cross-sectional
IV: Demographics,
Military history,
Perceptions &
preferences
DV: Use of VA
Healthcare: All,
Some or None
2005-2008
Two Midwestern
VA’s
Drilled down only
women with
telephone numbers
– (35.5% vs.
29.7%, p = .0004)
Satisfaction
Survey: 278/404
surveyed. 33%
counseling
influenced
decision, 56%
received BS, &
77% agreed
counseling should
be used for to
encourage nonresponders.
Preferences: WV
prefer female
provider (p = .002),
Perceptions: WV
agrees VA care is
good, feel safe, &
privacy.
Rural WV ↓ need
for separate
waiting area just
for women (p <
.01), or want a
Author Conclusions
rates.
To reach the
subgroup pop.
combination of
telephone
counseling & ↓
structural barriers
(free transportation
& cost)
Limitations,
Notes
numbers, problem
with making
contacts before
appts., no cost
analysis
Telephone
counseling was well
accepted by
participants &
effective.
WV want gender
specific care,
“female
“chaperone” during
exams, Care
preferences similar
irrespective of VA
use but higher with
WV users of VA
care solely than nonVA users.
Limitations: Nonresponse bias - 29%
never reached, selfreporting, &
generalizability
since selected
population from
Midwest, no
question if WV
knew that VA
provides gender
specific care.
55
1,002 woman 20-52
yrs old, 94%
enlisted with a
median of 4 years,
30% SA during
military service,
50% SA outside of
service.
Computer-assisted
telephone interviews,
using VisTa VA
software (1,002),
Health Survey Short
Form-12 (SF-12);
Post-traumatic
Symptom Scale
(PTSS) – 17 items;
Composite
International
Diagnostic Interview
(CIDI-SF) –
Key Findings
grp. (only letter)
(29.7% vs. 26.1%,
p = .0035)
Purpose
To document
characteristics of
WV challenges with
access to care
whether delayed
and/or unmet.
Design, Key
Variables
Descriptive,
Quantitative,
Cross-sectional
IV: Multiple IVs
DV: Access to care
(Washington, BeanMayberry, Riopelle,
& Yano, 2011)
Identified barriers to
access of care in the
Veterans Health
Administration
(VHA) for WV.
(Vogt et al., 2006)
Sample/Setting
Stratified random
sample based on VA
use & nonuse, prior
service. Exclusion
criteria - currently
serving, VA
employee or
institutionalization
(3,611 consented)
Descriptive,
Quantitative,
Cross-sectional
IV: Multiple IVs
National Survey of
Women Veterans
Telephone Survey
Consumer
Assessment of Health
Plans Survey
(CAHPS)
5 focus groups to
probe for potential
problems to
accessing care.
Barrier themes
identified & items
established to report
Key Findings
chaperone in room
(p < .05), or
treatment by male
or female provider
(p < .01)
Author Conclusions
WV that
experienced delay
or went without
healthcare in prior
12 months (18%),
uninsured (54.6%),
insured (14.3%)
Nearly 1 in 5 WV
deferred healthcare
or went with unmet
needs in prior12
months.
WV with deferred
care or unmet
needs related to
those without –
racial ethnic
minorities, lacked
consistent provider,
uninsured, low,
income, fair or
poor health,
disabled, mental
health diagnosis.
Availability of
women- specific
services - strongest
predictor of VHA
use by WV.
Additional barriers:
MD sensitivity,
Limitations,
Notes
Limitations:
Sampling problem
with those without a
telephone.
Access barriers
challenging recognized VA’s are
in position to create
programs to
counterbalance SES
& insurance-related
barriers.
WV perceived VHA
care to be similar to
other facilities. WV
identified 2 areas for
focus: 1) improving
logistics (waiting
time, continuity of
care) & 2) women-
Limitation:
Sampling bias of
self-selection
Notes: Older article
– appropriate for
benchmark data &
awareness of factors
56
DV: Barriers to
care
NRWV database –
stratified random
sampling – a subset
of a larger sample
(942 total - 543
current VHA users
& 399 former users)
Measures
depression scale;
Lifetime Sexual
Assault (LSA);
WV preferences &
perceptions
interview – 5 point
Likert scale
2008 – 2009
Purpose
Design, Key
Variables
Sample/Setting
Measures
each of the themes
for telephone survey.
SF-36 Health Survey
using a 5-point scale
What are deterrents
& influences that
affect why WV
chose to use or not
use Veteran Affairs
(VA) Healthcare?
(Washington, Yano,
& Simon, 2006)
Descriptive,
Quantitative,
Cross-sectional
IV: Multiple IVs
DV: WV Use or
nonuse of the VA
Healthcare
WV users & WV
non-users –
Southern California
& Southern Nevada
(2,174)
Randomly selected
– stratified by
ambulatory care
(VA use, VA
Nonuser), age group
(< 50, 50 & older)
Telephone Survey
(March – September
2004) VA utilization,
attitudes toward care
& sociodemographics
CAHPS & SF-12
Key Findings
logistics of care,
facility/physical
environment,
insurance
coverage, health
status, & disability
ratings.
Author Conclusions
specific services.
Reasons for use of
VA care –
Affordability
(67.9%),
availability WHC
(58.8%),
convenience
(47.9%).
Reason for
nonuse– have
personal insurance
(71.0%), non-VA
care more
convenient
(66.9%), not aware
of available female
services (48.5%),
non-VA care
perceived to be
better (34.5%).
Multiple reasons for
non-use of VA
services – lack of
knowledge about
VA care,
perceptions about
excellence of care,
untimeliness of care.
Socio-demographic
similarities of
VA/non-VA users age, race-ethnicity,
period of service.
Limitations,
Notes
for potential
recommendations.
Limitations:
Only people with
telephones, Southern
California &
Southern Nevada
Notes:
Benchmark of where
VA has been &
provides statistics
that would have
included VA Long
Beach - Part of
Veterans Integrated
Service Network 22
(VISN22)
Targeted population,
findings can support
recommendations
for focused practice
change
57
Purpose
Utilizing a
conceptual
framework to
identify social &
economic factors of
WV in the United
States that affects or
influences the
demand for mammo
screenings.
(Lairson, Chan, &
Newmark, 2005)
Is absence of
screening, detection
or follow-ups
contributing factors
in late-stage breast
cancer?
(Taplin et al., 2004)
Design, Key
Variables
Descriptive,
Quantitative,
Cross-sectional
Design
Sample/Setting
National Registry of
Women Veterans
(NRWV) – random
sample – (3,415), 3
x 2 strata
IV: Multiple IV’s
(28) specified as
categorical
2 cohorts - Fall 2000
& Summer 2001
DV: binary
variable did get a
mammo & did not
(WV getting a
mammo for
diagnostic were
excluded)
Descriptive,
Retrospective chart
review
Cancer Research
Network (7 health
care plans)
Assigned women
into 2 groups based
on the stage of
their breast cancer
at diagnosis.
Mail survey with
telephone follow up
Michael Grossman’s
model demand for
health & medical care
framework understand utilization
of preventative
medical care
Comparisons
between the 2 groups
– logistic regression
for matched pairs.
Models included age
and year of diagnosis
Cochran-MantelHaenszel statistic
used to conduct a chi-
Limitations,
Notes
Key Findings
VA users’ ≥
unemployed
disabled, < $20,000
annual income,
uninsured, have
service-connected
disability, (p <
.0001).
Author Conclusions
Significant:
Insurance,
income, apparent
risk, smoking
practice, & waiting
& exam time
Grossman’s
framework fails to
consider
uncertainty. Age &
poor health status –
not directly related:
education,
insurance, income &
perceived risk
directly related to
probability of use of
screening BS.
Limitations:
Limited data on BS
& other preventative
health behaviors for
WV.
In order to reduce
late-stage cancer,
setting priorities for
screening
improvements can
help to identify gaps
in the screening
process. Knowing
the potential
breakdown areas in
Limitations:
Using chart review
data imposes
inherent limitations
of observational
research. Unknown
characteristics of
case subjects
excluded from
sample from 2 sites.
Not Significant:
Age categories,
education levels,
marital status,
health conditions,
race, & travel time
Not Significant:
Hispanic origin,
race, marital status,
family history of
breast cancer,
median household
income, or
education
Significant:
Notes: Four key
lessons to help
remove barriers &
decrease disparities
in the conclusion
section.
58
1347 Case Subjects
(metastatic and/or
tumor ≥ 3 cm &
1347 Control
Subjects (earlystage)
Measures
Purpose
Design, Key
Variables
Sample/Setting
Measures
square test
Unconditional
logistic regression –
association between
absence of screening
& variables of
interest among case
subjects
What types of
mammo outreach
interventions are
successful with the
current population of
WVs?
(Dalessandri,
Cooper, & Rucker,
1998)
Random Controlled
Trial (based on
even & odd
endings of SSN)
Randomly assigned
into 2 Groups –
717 underserved
WVs
VA Palo Alto
Healthcare System
(VAPAHCS)
Group 1 (351)
control – sent
information on need
for mammo, letter
included identifying
if due for mammo or
if felt a lump.
Over 6 month period
– did or did not
receive mammo
Demographics
were similar
Author Conclusions
communication and
follow-ups can
provide a guide for
establishing the
priorities for
improving the
screening process.
Limitations,
Notes
Used data from 4 of
the 7 sites –
uncertainty of the
overall estimated
amount of women
with invasive cancer
in the target
population
Notes: Supports
need to track and
reach out to screen
women who have
not had a mammo in
last 2 yrs.
Having a nurse
follow up call to
schedule & answer
questions resulted in
5-fold improvement
over 6 months.
Barriers to regular
mammos (cost, lack
of referral by a
health care
professional, lack of
general education
about breast cancer
& mammo
Notes:
May only be
generalizable to
other VA facilities.
Older data, good
study to be
benchmark &
compare current
practices
No assessment of
education level or
reference to literacy
level of brochures –
59
Group 2 (366)
Intervention - sent
above plus received
Demographic data
questionnaire (age,
branch of service,
marital status, race,
employment status)
Key Findings
Screening Absence
(all women) higher
incidence of latestage cancer (OR =
2.77, 95% CI =
1.84 to 2.56; p <
.001)
Case pts. 75 yrs. or
older more likely in
absence of
screening group
(OR = 2.77, 95%
CI = 2.10 to 3.65),
unmarried (OR =
1.78, 95% CI =
1.41 to 2.240, or no
family history of
breast cancer (OR
= 1.84 95% CI =
1.45 to 2.34)
17 in Group 1
versus 100 in
Group 2 received a
mammo (p < .01)
Purpose
Design, Key
Variables
Explored possible
predictors of WV in
mammo use.
Descriptive,
Quantitative
Design
(Hynes, Bastian,
Rimer, Sloane, &
Feussner, 1998)
IV: Predictors
DV: Women
Veterans mammo
use
Sample/Setting
a call from a breast
care nurse – if no
response within 45
days from mailer.
Defense Manpower
Data of U.S. DOD
& national VA
databases at the
Austin (Texas)
Automation Center.
All living WV
discharged 19711994
Two-phase
sampling:
Age ≥ 35 years old,
served 18 months &
discharged 19711994 (20,000 WV
met criteria – 10%
sample taken)
Stratified random
sample (n = 397) to
complete pilot
survey & tracking
technique
Attrition – final (n =
290)
Limitations,
Notes
may have impacted
results.
Measures
Key Findings
Author Conclusions
Telephone survey – 2
purposes (pilot
survey, pilot tracking
techniques)
Demographics 44% - total VA
users, 39% (114)
50-64 yrs., 12%
(34) ≥ 65 yrs., 10%
black, 40% spent
3-9.5 yrs. in
service, 36% spent
> 9.5 yrs.
Future studies need
to focus on provider
patient
communication,
increasing
provider’s
participation in WV
discussions.
Limitations: Pilot
survey – possible
overstated BS rates,
inability to
distinguish between
screening &
diagnostic mammo,
small sample size
First study to
examine factors that
affect BS use among
WV.
Notes: Did not
provide questions
used in the survey –
102 questions are a
lot of questions. Was
it validated &
reliable?
102-item survey &
on 100 subjects
Subset of 102-item
survey & tracking
techniques
60
Weighted logistic
regression model
for predicting BS
(BS use ever) WV advised to
have BS [OR 5.41,
CI 4.64-6.32], (p =
≤ .001)
WV 50-64 yrs.
↑have BS than 3549 yrs. [OR 4.65,
CI 2.16-9.98], (p =
≤ .001)
Black WV ↓ to
have BS than
nonblack [OR 0.65,
CI 0.53-0.79], (p =
≤ .001)
WV used VA in
last 5 years ↑ BS
[OR, 1.68, CI 1.34-
Purpose
Design, Key
Variables
Sample/Setting
Measures
Key Findings
2.11], (p = ≤ .001)
Author Conclusions
Limitations,
Notes
Notes. AOR = Adjusted Odds Ratio, BRFSS = Behavioral Risk Factor Surveillance System, BS = Breast Screening, CRS = colorectal screening, CI =
Confidence Interval, CAHPS = Consumer Assessment of Health Plans Survey, DOD = Department of Defense, DV = Dependent Variable, IV = Independent
Variable, IRB = Institutional Review Board , mammo = mammography/mammogram, MST = Military Sexual Trauma, NRWV = National Registry of Women
Veterans, n = number per group, OR = Odds Ratio, OEF/OIF/OND = Operation Enduring Freedom, Operation Iraqi Freedom, Operation New Dawn, PC =
personal call, pop. = population, RCT = Randomized Control Trial, SA = Sexual assault, SSN = Social Security Number, SES = Socioeconomic status, UK =
United Kingdom, U.S. = United States, VA = Veteran Affairs, VAPAHCS = Veteran Affairs Palo Alto Healthcare System, VHA = Veterans Health
Administration, VISN22 = Veterans Integrated Service Network (22 is the region), WHC = Women’s Health Clinic, WV = women Veteran, yrs. = years old
61
Table 2
Integrated Review: International Women Population and Factors Affecting Breast Screening Compliance
Purpose
To explore factors
that influence
having breast cancer
screenings.
(Edgar, Glackin,
Hughes, & Rogers,
2013)
Design
Integrative Review
Sample
12 research papers
Aim: To critically
review factors
which can influence
women’s decisions
to get breast cancer
screenings?
Integrative review
included U.S., UK,
Australia, & Canada
& Arab countries.
Findings
4 BS influenced
themes
1.
2.
Multiple types of
research studies
included: Primary
research, theoretical,
qualitative,
quantitative,
published from
2000, including
explicit themes
related to topic
3.
4.
Psychological,
real-world
issues,
Concerns
related to
ethnicity,
Impact of SES,
&
Problems
related to
programs
Mistaken
perceptions &
underestimation of
individual risk
related with low
compliance.
Conclusions
Regardless of
demographics,
cognitive &
psychological
factors can influence
screenings & can be
used to educate &
improve knowledge.
Limitations, Notes
Women overestimate
benefits, lack knowledge
of risk associated with
mammos. Women should
be provided balanced
information about risk &
benefits of breast cancer
screenings.
Values & beliefs
need to be
considered.
Notes: While this review
was completed in the UK,
there are some
commonalities between
the U.S. & UK.
Literature should be
delivered in primary
language.
Some providers fail
to make use of
opportunities.
Cultural background
influential in
screening
participation.
Some health care
professionals “… do
not appreciate the
value & impact of
discussing mammo
screenings & fail to
make use of
Mammo rates
significantly lower
for women from ↓
SES backgrounds, ↓
level of education,
with ↓ access
screening
62
African American
woman screening
rates < Caucasian.
Purpose
Design
Sample
Findings
opportunities to
raise awareness of
breast cancer risk
factors.” (p. 1025)
Conclusions
information &
therefore do not
recognize the
benefits of early
detection.
Limitations, Notes
Note. BS = breast screening, mammo = mammogram/mammography, SES = socioeconomic status, UK = United Kingdom, U.S. = United States
63
Table 3
Systematic Review: Value of Interventions to Improve Screenings for Breast Cancer
Purpose
Evaluates
intervention to
increase
recommendations &
deliver by
healthcare providers
Design
Systematic Review
Sample
Studies between
1986 to November
2004
26 studies included
Inclusion Criteria:
(Baron et al., 2010)
a)
Primary
scientific
publications,
b) Reported using
provider
reminders, &
c) Good quality of
execution.
Findings
Effectiveness:
BS ↑ median of
10% (IQI, 3.0%19.0%) – no
significance
regarding method of
prompt (electronic
vs manual),
distribution, content,
format (clientspecific vs generic),
or provider
experience.
Conclusions
Robust evidence –
provider prompt &
recall systems
provide positive
results
Applicability:
BS ↑ in completed
screening,
recommendations,
or ordered
screenings.
Intervention(s) to be
utilized will rely on
familiarity of local
setting, culture,
needs, repeat hx, &
delivery choices.
Limitations, Notes
Review does not provide
specific guidance for
which recommended
intervention is most
applicable for a
population or setting.
Applicable across
wide variety of
clinical settings,
pt./provider
population, plus
irregularly or never
screened patients.
Economic
Efficiency:
BS cost
effectiveness for
tagging charts of
women who
received routine
mammo, & for
failed attendance in
the past when they
were due.
64
Purpose
Evaluates
effectiveness of
interventions to ↑
BS, Cervical, &
Colorectal
screenings.
(Sabatino et al.,
2012)
Design
Systematic Review
update for the GCPS
Sample
9 interventions
reviewed
Findings
Increasing
Community
Demand for BS
45 studies included
Studies between
January 2004 to
October 2008
Inclusion Criteria:
a)
Primary
investigation of
one or more
interventions,
b) Conducted in
high-income
economy
country,
c) Obtained one
cancer
screening,
d) Screening use
prior to
intervention
execution, &
e) Current group
not exposed to
intervention
Recommended:
Sufficient evidence (a) group education
Recommended:
Strong evidence (a) individual
education, (b) client
prompt
Insufficient
evidence – (a) client
incentives, (b) mass
media
Increasing
Community Access
to Screening for BS
Conclusions
Local needs,
barriers,
populations,
resources, evidence
data – need
consideration in
choosing effective
interventions.
Limitations, Notes
No limitations listed by
authors.
Note: potential influences
that need to be further
studied – Communication
(e.g. texting, internet, email, social media &
AIVR)
Evaluation of
interventions that
worked – significant
stage to improve
increase screening.
Critical to
disseminate findings
of effective
interventions to
maximize utility
Recommended:
Sufficient evidence
– (a) reducing
personal cost
Recommended:
Strong evidence –
(a) reducing
structural barriers
65
Increasing
Provider Support
of Screening for BS
Purpose
Design
Sample
Findings
Conclusions
Limitations, Notes
Recommended:
Sufficient evidence
– (a) provider
assessment &
feedback
Insufficient
evidence – (a)
provider incentives
Note: appt. = appointment, AIVR = automated interactive voice response, BS = breast screening, GCPS = Guide to Community Preventive Services, hx =
history, IQI = interquartile interval, mammo = mammogram/mammography, pt. = patient
66
Table 4
Table of Evidence for Qualitative Studies
Purpose
To explore WVs
views &
considerations about
VA healthcare use.
(Washington,
Kleimann, Michelini,
Kleimann, &
Canning, 2007)
Conceptual
/Theoretical
Underpinnings,
Design
Ethnographic
Qualitative,
exploratory, &
descriptive.
Sample & Setting
51 VA eligible
WVs
Met in
professional focus
group (grp)
settings
Recruited through
facility contacts
& mailed
invitation letter.
$50 incentive for
time
Results;
Theoretical Integration
Focus grps represented a range
of ages & demographics, 47%
VA users below federal poverty
level, with no nonusers in this
category, 62% VA users & 94%
on nonusers had health
insurance.
3 major themes developed as
qualities WVs seek in their
healthcare: (a) access, (b)
gender appropriateness, & (c)
quality. Same 3 themes
appeared for decision-making
about VA use with an additional
theme of information needs.
Barriers – lack of knowledge of
services & eligibility – nonusers
no aware of WV services
Users/nonusers expressed a
requirement for quality &
gender sensitivity care.
Users/nonusers views of VA
quality differed. VA setting
(male dominated) concerns was
identified as a limitation of use.
Author Conclusions;
Limitations; Notes
Perceptions, experiences,
environmental, & quality
concerns are often related to
WV healthcare needs which
can contribute & influence
their choice in deciding to
use VA care. There is a
knowledge gap about the VA
eligibility & WV services.
Study conducted in one
geographic area is a
limitation.
This study informs the VA
about WV perspective on VA
healthcare & the results
should be priority areas for
improvement as identified by
the WVs.
67
Data Collection,
Management &
Analysis
6 focus grps – stratified
(VA use & age grp), 4
grps (used VA with in
past 5 yrs.), 2 grps
(never used VA or not
used in last 5 yrs), 2
VA-user grps & 1
nonuser were with WVs
having served before
1980, remainder grps
with WVs severing
since 1980.
11/2 to 2 hours audio &
videotaped. Semistructured interviews,
written survey to collect
demographic info.
Transcript-based content
analysis – grounded
theory methodologyGlaser & Strauss, data
analyzed by coding till
themes/categories fully
developed with constant
comparison method by
all 3 investigators, to
enhance reliability 2
additional investigators
used same process,
representative quotes
Purpose
Conceptual
/Theoretical
Underpinnings,
Design
Sample & Setting
Data Collection,
Management &
Analysis
extracted supporting
themes & tones
communicated.
Results;
Theoretical Integration
Author Conclusions;
Limitations; Notes
Note: grp(s) = group(s), info. = information, VA = Veterans Affairs, WV = women veteran, yrs. = years
68
Table 5
Use of Databases to Improve Clinical Outcomes
Purpose
Improving quality and
efficiency interventions
for breast cancer
screenings in a
heterogeneous primary
care network.
Design
Performance
Improvement Mammography
FastTrack (MFT)
installation and
implementation usage
(Lester, Ashburner,
Grant, Chueh, Barry, &
Atlas, 2009)
Utilizing technology to
improve workflow.
(Corkery, 2007)
Sample
Massachusetts General
Primary Care Network
(MGPCN) – over
150,000 patients (pt.),
180 primary care
physicians (PCP)
3,054 eligible pts.
64 PCP managed pts. –
1,689, 6 Case Manager
(CM) managed pts. –
1,365 – tested in 6
primary cares within
network
Performance
Improvement
4 Inpatient
Rehabilitation Care
Management Team
(IRCMT) members,
admissions nurse
(ARN), nursing
administrator
Questionnaires and
meetings used to assess
what was working and
what was not.
Findings
After 6 months – 86%
of PCPs & all CMs
used a portion of MFT,
PCPs intervened in
83% of overdue
mammograms (letters
sent and or deferred
contact), 63% pts.
successfully contacted.
Duplication (over 300
data items used more
than once) in work
processes found in
existing paper system
Timing trial – 3 to 3½
hours of redundancy
Conclusions
Technology integration
success is supported by
accommodating the
PCP, practice workflow
in flexible
environment, simple
and convenient
screenings, automated
surveillance and pt.
outreach methods.
Identify strengths and
weaknesses of process
and integrate into
planning.
Consideration of endusers – satisfaction is a
direct link to
participation and
bidirectional
communication.
No system in place to
identify or send
reminders for overdue
mammograms
System requires
manual upload of at
risk population,
mammography due
dates & updated link to
provider.
Designing takes
considerable time and
effort
Loss of real-time
reports and statistics Information
Technology (IT)
personnel required to
export from both excel
and the web-based
database into the
departments database
Original design not
69
Time-saving – partially
achieved
Limitations, Notes
Even with
considerations of
allowing as much local
workflow flexibility –
unable to meet every
practices preference.
Purpose
Evaluating a user
satisfaction with a
clinical database.
(Hortman &
Thompson, 2005)
Design
Sample
Findings
Conclusions
Descriptive,
Quantitative
Midwestern College of
Nursing
Individual QUIS results
ranged from 3.0 to 8.0.
There is no one size fits
all.
Evaluating a mock
nurse practitioner (NP)
outcomes database –
developed to track
clients clinical
outcomes
Convenience sample –
5 faculty NPs
Overall user
satisfaction moderately
high.
Designers can get too
close or too
comfortable with
design and may not
recognize existing
problems.
Questionnaire for User
Interaction Satisfaction
(QUIS) – Demographic
data, 12 parts with 2 &
7 excluded.
Limitations, Notes
used – change in
project – project
champion transferred
out of department
QUIS – developed at
the University of
Maryland in 1980s –
Cronbach alpha of
0.95, Likert scale 1 – 9
Small sample size
Formal evaluation and
observation important
part of the design
process
Note: ARN = Admissions Nurse, NA = Nursing Administrator, IT = Information Technology, IRCMT = Inpatient Rehabilitation Care Management Team, MFT
= Mammography FastTrack, MGPCN = Massachusetts General Primary Care Network, NP = Nurse Practitioner, pt. = patient, PCP = Primary Care Physician
QUIS = Questionnaire for User Interaction Satisfaction.
70